The columns for the past two weeks have addressed the basic thought problems that result in depression.  The problem begins when reality does not match the expectation or desired result.  Last week it was pointed out that once the disappointment occurs, the depression is increased by a thought defect in which the person accepts the disappointment as being their own fault as they are inferior and always will be.  These three beliefs are intrinsically false and mire the person in the past.

     It was pointed out that counseling with a friend, clergyman, or professional counselor often would cycle a person out of a depression problem.  But as was pointed out, such individuals are difficult to find.  When “talk therapy” is not available, a second alternative is to use medications.

     In the many years that depression has been studied, it has been shown that there are disruptions in the chemicals involved in thought processes.  Over the years, a large number of medications have been developed that change the chemistry of the brain allowing it to resume normal activity and arrest the depression.

     Anti-depressant medications characteristically take two to six weeks to show a clear benefit.  On the average, 60% of any depressed population will respond to a given medication.  If patients do not respond to the first medication tried, often replacement with a second medication will lead to a response in over 80% of people so treated.  Thus, four out of five individuals who have depression problems are benefited by anti-depressant medications.

     Over the years, three broad classes of anti-depressant medications have become available. Recently a number of an “atypical-category” of medications has been developed.  The very first anti-depressant was developed in the mid 1950’s and belongs to a class of drugs called monoamine oxidize inhibitors (MAOI).  The side effects from these drugs were substantial and today there are only two such products on the market, Nardil and Parnate.  These drugs are infrequently used, not because they are ineffective, but because of the side effect profile that is substantial and dangerous.

     The second group of drugs that came on the market was called a “tricyclic anti-depressant”.  These included Amitriptyline which is now a generic drug and very cheap.  Others in this group included Nortriptyline and Antipyrine.  These drugs all have prominent side effects including drowsiness, dry mouth and rapid heartbeat.  They are relatively and infrequently used today because of the side effect profile.  They are effective in treating depression but in today’s world, at too great a side effect profile. Amitriptyline has alternative uses as a sleeping pill and as a block to nerve pains in the hands and feet.

     By far, the largest group of anti-depressant medications used today is called the “serotonin reuptake inhibitors” (Lexapro, Celexa, Prozac, Paxil, Zoloft). This family of drugs is probably no more effective than the tricyclic group mentioned above, but the side effect profile is substantially lower.  Problems with dry mouth, drowsiness, and palpitations are much less.  Some patients do have slight nausea or headaches when starting this family of drugs but these symptoms usually resolve.  Sexual dysfunction in both men and women is a frequent side effect of this family of drugs.

 Wellbutrin (bupropion) is an atypical anti-depressant with the advantage of no drowsiness, dry mouth or sexual dysfunction.  It has the fringe benefit of being the backbone of anti-smoking programs.  The drugs somehow decreases cigarette craving. Desyrel (trazadone) is an atypical anti-depressant infrequently used for this purpose.  More commonly, trazodone is used as a sleeping pill, especially in the elderly.  Effexor (venlafaxine) is an atypical anti-depressant drug that is also very effective with a low side effect profile and is reasonably priced.

     Most people with depression are not psychotic.  That is to say, they do not believe things that are patently incorrect, unrealistic, or wrong.  Depressed individuals with psychotic symptoms become more complex, and frequently require hospital treatment for a period of time.

     Depression strikes approximately one in ten people in our population at sometime in their life.  It is the leading cause of lost time from work.  It is an excessive medical expense because people are reluctant to admit they have a problem with depression.  By the same token, physicians are reluctant to make the diagnosis and insult the patient who seeks medical attention because of headaches, backaches or other symptoms that are really a manifestation of the depression.  The healthcare providers at your local clinics are aware of these problems. They are  very helpful in guiding a person through a depression, with or without medications or referring the person on to psychiatric help, if necessary.